No matter which presidential candidate Ohio supports this November, the state itself is facing some tough and unavoidable choices.

First among them is this: Whatever a voter thinks of President Barack Obama’s Affordable Care Act, that law will at best slow, but not stop, the rise in health-care costs.

In 1965, Ohio opted into the federal-state Medicaid program. (And, be it noted, Republicans ran the Statehouse.) By 1969, Ohio’s annual Medicaid outlay was $129 million — about $12 per Ohioan. This year, Ohio’s Medicaid outlay is $18.8 billion, or about $1,630 per Ohioan. Even after inflation, that’s a bite.

The number of Medicaid-eligible Ohioans has exploded. Roughly 20 of every 100 Ohioans already are Medicaid clients. Next time you’re at the mall, or at an athletic event at your daughter’s or son’s high school, count off other shoppers or fans. If you pay taxes, you’re theoretically paying doctor and prescription bills for every fifth person you see.

That’s why state government should be, has to be, more about management than politicking. Voters who get their Dockers in a bunch over Democrat Obama’s birth certificate, or Republican Mitt Romney’s tax return, or Republican Gov. John Kasich’s quirky personality, are defining politics as just an extension of the National Football League by other means.

True, it’s a free country (sort of). So Ohioans can look at state government any way they want to. But when the Romney-Obama presidential contest is a hazy memory, and after Kasich’s governorship ends — in 2015 or, if he’s re-elected, in 2019 — Medicaid costs still will be there, and won’t drop. So Medicaid options now being debated by policy-making Kasich appointees and career public administrators will help determine Ohio’s financial future. (Former Gov. Ted Strickland’s capable Medicaid team got the talk started.)

A study by respected Statehouse public-policy veteran Terry M. Thomas outlines the dilemmas Ohio faces. Thomas, once president of the state Controlling Board, was founding executive director for the Ohio Association of Community Colleges. His article “Longitudinal Look at State Spending” appears in the latest online State Budgeting Matters review, distributed by Greater Cleveland’s Center for Community Solutions. Among his findings:

• “Medicaid is Ohio’s largest and fastest-growing expenditure program. On an inflation-adjusted basis, (Medicaid) is the only major state program experiencing any growth in the last decade.” Be it noted, though, that “when only state-source funds are considered” — that is, not counting federal funds — “Primary and Secondary Education continues to be the largest spending category.”

• “Fast-rising Medicaid expenditures are absorbing what little state budgetary growth remains. (And) Ohio’s senior population is growing much faster than its population overall, especially those over age 85. By 2020, the number of Ohio seniors will likely exceed the school-age population for the first time, further stressing future Medicaid and state budgets.” Thomas noted a partial offset: More Ohioans 65 or older likely will keep working.

• And state income-tax cuts and weak growth in personal income will tighten the Vise-Grips: “Fewer *(Ohioans) earning comparatively less and paying comparatively less in taxes will be working to support the health-care costs of an ever growing number of older Ohioans.”

Kasich, through his Governor’s Office of Health Transformation and its director, Greg Moody, is tackling these dilemmas. If politics were just a sport, it’d be easier to duck them. But Medicaid policy isn’t Sunday afternoon in the Dawg Pound. What began as a 100-word Ohio law is now thicker than a stack of phone books. Medicaid reform is a long, hard slog. Kasich and Moody dived in, anyway — because somebody had to, and, until now, few in Columbus would.